Please fill out the following sections as completely as possible. Along with this client intake form, kindly read, review and sign the Service Agreement which may be accessed here.

Thank you for taking the time to fill out this form. Having this information prior to our first prenatal appointment helps me to utilize our time together more effectively and serve you better. If you have any questions, please do not hesitate to ask.

Please note, this information is private and will not be shared with any parties with out your express consent. 

    Information about you

    ​Alternate/Additional Support Person (If you have one)

    Information about your Care Providers

    Information about your pregnancy + upcoming birth + postpartum

    Because of the unique challenges of birth, it is possible that a prior trauma or violent incident can impact your birth experience. By being aware of this I can better serve you, however, please share only what you are comfortable with.